The management of hypertension in patients with benign prostatic hyperplasia and erectile dysfunction

Lowering elevated blood pressure reduces mortality and the risk of stroke, coronary heart disease and heart failure.
The presence of benign prostatic hyperplasia (BPH) is a compelling indication for the use of an alpha blocker in the treatment of hypertension. Alpha blockers are first-line therapy for men with lower urinary tract symptoms (LUTS) and prostatic hyperplasia. In men with prostates larger than 30 cm3 or prostate-specific antigen > 1.4 ng/ml, 5-alpha reductase inhibitors may also be added. Typically, alpha blockers improve LUTS by 30–40% and maximum urinary flow rates by 16–25%, with clinical improvement within two weeks. The 5-alpha antagonists are only effective in men with a large prostate and may take up to six months to achieve their full effect.
The Medical Treatment of Prostatic Symptoms (MTOPS) study assessed the long-term effects of doxazosin, finasteride and combination treatment on symptom scores, the clinical progression of BPH and the long-term risk of complications. Combination treatment reduced the risk of clinical progression by 66%, a significantly greater reduction than that induced by either agent alone. The improvement in the symptom score was also significantly greater in the combination treatment group.
Erectile dysfunction (ED) may be a marker for other diseases, such as hypertension. ED is both more prevalent and more severe among patients with hypertension than among the general population. The link may be related to nitric oxide/cyclic GMP pathways and endothelial function. Many prescription drugs are associated with ED, including antihypertensive agents. The alpha blockers and angiotensin receptor blockers are the drugs least likely to cause ED, and may even improve the situation. All currently licensed ED treatments are suitable for managing ED in the cardiovascular patient, when used according to the manufacturer’s instructions. PDE5 inhibitors and alpha blockers should be temporally separated, or selective alpha blockers may be preferable, in order to avoid postural hypotension.

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